Failed Dynamic Graciloplasty

Abstract

Dynamic graciloplasty (DGP) has a diminishing but specific role as a method of reconstruction in selected patients presenting with incontinence. DGP is designed to restore fecal continence through the transposition of an autologous muscle capable of contracting either voluntarily or by electrical stimulation. Although it is evident that the inherent properties of the gracilis muscle are not optimal for the provision of continence, its supplementation with an implanted electrical stimulator provides more long-term, “automated” contraction. This dynamization of the gracilis muscle results in a specific conditioning of the muscle fibers from rapid twitch, easily fatigable (type II) fibers to tonic, slow contracting (type I) fibers to suit this purpose. This chapter describes the specialist approach to the failing DGP, which results from problems with the muscle or the dynamization process. There is a high rate of complications and revisions among patients implanted with a DGP, including infection, hardware failure, and postoperative evacuatory dysfunction. Specific complications include lead fibrosis, thigh seroma, stimulator erosion and exposure, fecal impaction, anal fissure formation, stimulator rotation, premature battery discharge, lead fracture, perineural fibrosis, and electrode displacement. The DGP may have a specific place in total anorectal reconstruction after abdomino-perineal resection and as a supplement in patients who were treated during childhood for congenital anorectal anomalies.